The PICCOLINO study randomly assigned 12,485 adults ages 55 to 64 years at six screening centers in Poland to participate in one of three invitation strategies for colorectal cancer (CRC) screening: control (invitation to screening colonoscopy only), sequential (invitation to primary colonoscopy and invitation for fecal immunochemical testing [FIT] for initial nonresponders), or choice (invitation offering a choice of colonoscopy or FIT). Compared with offering colonoscopy alone, offering active choice or sequential use of colonoscopy and FIT improved participation rates; however, combined strategies did not increase advanced neoplasia detection rates.
The study was published online on Dec. 8 by Gastroenterology. The following commentary by Thomas F. Imperiale, MD, FACP, appeared in the ACP Journal Club section of the July Annals of Internal Medicine.
Despite high-quality evidence that screening reduces CRC incidence and mortality, uptake remains lower than for other cancers. Whether screening is organized (e.g., country- or system-based) or opportunistic (most of the USA), neither the best screening strategy nor how best to present screening options is clear.
Pilonis and colleagues found higher participation rates with sequential and choice strategies vs. colonoscopy only. These results corroborate studies showing that noninvasive tests (such as FIT) or screening choice increase participation over colonoscopy. However, higher participation rates did not increase detection of advanced neoplasia (AN). And in post hoc analysis, detection of any adenoma was no higher in the 2 strategies that included FIT and was lower with the choice strategy than with colonoscopy.
Do these secondary results negate the positive primary finding? In my opinion, they do not. First, only 70% of participants with a positive FIT result had diagnostic colonoscopy, implying that both FIT-containing strategies underperformed. Second, outcomes were assessed after a single screening; strategies that include FIT require rescreening at 1- or 2-year intervals, whereas colonoscopy is the most sensitive single-application test for AN. Thus, it is not surprising that AN yield was no different. It was also not surprising that detection of any adenoma was lower in the choice strategy because nonadvanced adenomas rarely bleed; however, the clinical importance of these adenomas is not well-established.
Given results based on a single screening and lack of knowledge about longer-term outcomes, clinicians may use this information to tailor how they present opportunistic CRC screening to patients by integrating it with patient preference, estimated risk for AN, and likelihood of adherence to screening both up front and over time. For systems and countries with organized screening, the goal should be to tailor how CRC screening is presented on the basis of patient-specific features, all of which may eventually be obtained from electronic medical records, and to have interventions (e.g., navigation) in place to ensure colonoscopy is completed after a positive FIT result.